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From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak
From a crisis response
to institutional capacity
building:
Experiences from
Zimbabwe on
cholera outbreak
ZimbabweWHO/AFRO Library Cataloguing – in – Publication
From a crisis response to institutional capacity building: experiences from Zimbabwe on cholera outbreak
1. Cholera – prevention and control
2. Disease outbreaks – prevention and control
3. Emergencies – supply and distribution
4. Capacity building
5. Organizational Case Studies
I. World Health Organization. Regional Office for Africa
ISBN: 978-929023261-2 (NLM Classification: WC 264)
© WHO Regional Office for Africa, 2013
Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the
Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional
Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who.
int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should
be sent to the same address.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for
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by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted,
the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the
interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for
Africa be liable for damages arising from its use.
Disclaimer:
This report was prepared by the Ministry of Health and Child Welfare and the World Health Organization for sharing
experience with participants at the 2011 World Conference on Social Determinants of Health. The opinions expressed in
this report are those of the authors, based on experience gained in managing the cholera outbreak, in-depth interviews
with key informants and discussions undertaken for the purposes of developing this report.Contents
Acknowledgments............................................................................................................. iv
Abstract.............................................................................................................................. v
1. Introduction..................................................................................................................1
2. Context.........................................................................................................................3
3. Methodology................................................................................................................4
4. Results.........................................................................................................................4
5. Cost..............................................................................................................................9
6. References.................................................................................................................12
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
iiiAcknowledgments
This case study was prepared jointly by the Ministry of Health and the Social Determinants
of Health Unit, World Health Organization, Regional Office for Africa. Financial support
was made available through the Spanish Core Contribution Grant for Social Determinants
of Health (SDH) received by the Department of Ethics and Social Determinants of Health
of the World Health Organization. The overall aim of Spanish Core Contribution Grant for
SDH is to strengthen leadership and stewardship role of Ministry of Health to addressing
social and economic determinants of health. It supports documentation of country level
experiences in using intersectoral actions aimed at addressing the key social determinants
of priority public health conditions.
An earlier draft of this case study was included in a special collection of global experiences
on intersectoral actions which was widely disseminated during the World Conference
on Social Determinants of Health held in Rio de Janeiro, Brazil in 2011. At the country
level, the review process leading to the finalization of the case study generated multi-
stakeholder policy and strategy discussions on implementing intersectoral actions to
address social determinants of health.
The final product is a result of collective efforts of many individuals and organizations.
However, the drafting team included Dr Davies Dhlakama, Dr Portia Manangazira,
Director, Disease Control and Prevention, Ministry of Health & Child Welfare; Dr Anna
Miller, (Consultant); Mr Laxon Chinhengo, Ministry of Labour & Social Services; Dr Stanley
Midzi, WHO Country Office, Zimbabwe.
The overall guidance and technical inputs to the project from WHO Regional Office for
Africa are gratefully acknowledged, namely: Dr Tigest Ketsela, Director Health Promotion
Cluster; Dr Davison Munodawafa, Programme Area Coordinator, Determinants and
Risk Factors; Dr Chandralall Sookram and Mr Peter Phori; and Dr Eugenio Villar, SDH
Coordinator in WHO HQ, Geneva. We are indebted to the many people who made
valuable inputs throughout the process who cannot be mentioned by name. Last but
not least, we express great appreciation for the support received from the Government
through the Ministry of Health to conduct this activity.
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
ivAbstract
This paper evaluates the multisectoral response to the 2008/09 cholera outbreak in
Zimbabwe and examines the extent to which the social determinants of health (SDH)
driving the outbreak, in particular, water and sanitation, were addressed. The study
provides the evidence that determinants of health are important in that most drivers
of health consequences emanate from social, economic, political and environmental
spheres. It also showed that, in order to institute a comprehensive emergency response,
intersectoral actions to address the SDH driving the outbreak, particularly given the
prevailing context of poverty and national systemic constraints, were needed.
A comprehensive desk review of documented response efforts to the cholera outbreak of
2008/09 was undertaken. Key informants were identified and interviewed to provide their
experiences of the outbreak as well as suggest what could have been done differently. The
study also assessed whether the multisectoral collaboration contributed to addressing
the social and other determinants that caused and/or propagated the outbreak. The
study revealed that the combined multisectoral efforts eventually resulted in the control
of the cholera outbreak which was declared officially over in July 2009. There have been
reports of sporadic outbreaks thereafter, but the concerted efforts and multisectoral
measures put in place since December 2009 to address the identified SDH have enabled
the country to realize dramatic reductions in both cholera cases and deaths across the
country. Subsequently, almost a year elapsed without cholera cases being reported. This
outbreak demonstrated that responding to an outbreak requires addressing the health
emergency at the same time as the SDH.
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
vFrom a crisis response to institutional capacity building:
vi
Experiences from Zimbabwe on cholera outbreak1. Introduction
Between August 2008 and July 2009, Zimbabwe experienced a catastrophic cholera
outbreak which ultimately resulted in 98 592 cases and 4288 deaths. Fifty-five of
Zimbabwe’s 62 districts (89%) were affected. The overall crude case-fatality rate was
4.3%, well above the acceptable WHO level of 1%. 61.4% of all reported deaths took
place in the community1. This outbreak took place against a backdrop of increasingly
frequent outbreaks since 1998 as shown in Figure 1.
Figure 1: Cholera occurrence in Zimbabwe, 1975-2010
Source: Ministry of Health and Child Welfare, 2009
Previous outbreaks had been confined to discrete geographical zones, were of limited
duration and affected far fewer people. Notably, this unprecedented outbreak coincided
with heightening socioeconomic decline where water and sanitation infrastructure had
deteriorated to its worst level. Additionally, all six building blocks of the health systems
had virtually collapsed. Several risk factors were identified in this outbreak, including
inadequate and unsafe water sources, poor sanitation and poor personal hygiene in both
urban and rural areas. The mobility of populations within urban areas, and from urban to
rural areas, became major factors in the spread, with an ongoing shortage of health care
workers limiting early detection, reporting and management of the outbreaks.
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
1
Evaluation of the Health Cluster Response to the Cholera Outbreak in Zimbabwe, Centre for the Evaluation of Public Health
Interventions (CEPHI), Department Of Community Medicine, University of Zimbabwe and the World Health Organization.
1Figure 2: Trends in cholera cases and deaths over time
Source: Ministry of Health and Child Welfare, 2009
The outbreak began in Chitungwiza municipality, a high-density suburb, and quickly
spread to adjacent Harare where the predisposing factors of chronic severe water
shortages, compounded by dilapidated sewerage systems, created fertile ground for the
spread of diarrhoeal and related diseases. The severe shortage of water forced residents
to the water from shallow wells which were contaminated with sewage flowing from the
burst sewer systems.
It is also important to note that the six building blocks of health systems were severely
weakened in terms of the ability to mount a timely and adequate response to the outbreak.
Experienced health workers were few and poorly motivated to deliver a prompt and
effective response. The health information system was severely affected by the prevailing
context of poor telecommunications, erratic electricity supplies, lack of radio networking
and inadequate transport. The remaining health workers on the ground were also over-
stretched and not trained to deal with the increasing numbers of cholera cases and
deaths. This affected timely and adequate documentation of all cases at the beginning
of the outbreak. As such the surveillance data were initially of very low timeliness and
completeness, further complicating an understanding of the outbreak and making
prompt action difficult. In response, donors and partners with the means complemented
and assisted in strengthening data collection and transmission.
From a crisis response to institutional capacity building:
The initial response to the outbreak was based on existing Ministry of Health and Child
Experiences from Zimbabwe on cholera outbreak
Welfare (MOHCW) policy and implementation frameworks for epidemiology and disease
control. Additional support coming in from health partners on the ground was on an ad
hoc basis. However, by 10th December 2008, the situation had deteriorated significantly.
From a total of 30 cases by the 1st of September 2008, the number had quickly escalated
to over 15 500, reported in nine out of the ten provinces of the country. The scale of
the outbreak had exceeded what the MOHCW had experienced before, with the worst
previous outbreak in 1999 reporting a total of 4081 cases in six provinces2. It was clear
that there was no surge capacity; a severely depleted and demoralized health workforce
2
Evaluation of the Health Cluster Response to the Cholera Outbreak in Zimbabwe, Centre for the Evaluation of Public Health
Interventions (CEPHI), College of Health Sciences, Department of Community Medicine, University of Zimbabwe; and the World
Health Organization.
2with no previous cholera outbreak management capacity, very limited resources, limited
information and compromised logistics because of the prevailing national crisis.
The increasing severity of the situation typified by high numbers of cases and high case-
fatality rate (CFR) increased anxiety and created panic within the population, health care
workers and development partners, especially WHO and UNICEF. This culminated in
the declaration of the outbreak as a National Emergency on 6th December 2009 by the
Government of Zimbabwe, through the MOHCW.
The need for a coordination platform for all stakeholders responding to the emergency led
the MOHCW and WHO to establish a joint command and coordinating mechanism, the
Cholera Command and Control Centre (C4). The location of this command centre should
have been the MOHCW/HQ premises. However, at that time, the MOHCW premises
did not have functional sanitation facilities and its location within a government security
building presented difficulties in the necessary round-the-clock access. As such, the
WHO Office Annexe was selected to host the C4 coordination meetings. While this meant
that resources for C4 did not come directly to building capacity in the MOHCW, it also
meant that the centre was able to function at full capacity as quickly and effectively as
possible.
2. Context
Cholera is a diarrhoeal disease caused by the bacterium Vibrio cholera, usually transmitted
through faecally-contaminated water or food. Cholera has a very short incubation period
of 2 hours to 5 days, and if left untreated, the severe loss of large amounts of fluid and
salts can lead to dehydration and death within hours. Outbreaks occur in environments
where water supply, sanitation, food safety and hygiene are inadequate. For this reason,
the control of cholera demands a multisectoral approach with stakeholders who will
address these socioeconomic parameters.
The macroeconomic contextual factors prevailing at the onset of the outbreak included
negative gross domestic product and massive hyper-inflation, with a severe lack
of resources. Socio-political challenges included a recently disputed election with
unresolved government status and sanctions against Zimbabwe. These combined
factors contributed to a number of severe additional challenges for the country, including
From a crisis response to institutional capacity building:
high unemployment, attrition of skilled and experienced health workers, food insecurity,
Experiences from Zimbabwe on cholera outbreak
shortages of basic commodities, reduced household incomes, transport failures,
shortages of medical supplies and commodities, closure of many health facilities and
progressive dilapidation of infrastructure, including the water and sewage systems.
The case-fatality rate (CFR), or the proportion of patients dying from cholera, was reported
to vary across cities, provinces and districts and highlighted a number of key inequities
in places of residence, wealth group, sex, race and occupational and educational levels.
Additionally, the underlying prevalence of co-morbid conditions such as HIV, cardiac
conditions and malnutrition appeared to compound cholera mortality. The majority (61%)
of deaths occurred in the community due to factors such as limited geographical access,
lack of commodities such as sugar and salt to make salt sugar solution (SSS) at home,
soap for hand washing, lack of awareness and access to adequate information and
3lack of knowledge about how cholera spreads2. Late responses to clinical cases were
seen due to low numbers of nurses and doctors, EHTs and VHWs on the ground, poor
communications and a failed referral system.
These inequities can be understood to have arisen from the unaddressed social
determinants of health , which included:
• Individual factors – no cholera immunity within the general population as previous
outbreaks of cholera had been sporadic, weakened immune systems due to HIV and
AIDS, and poor nutritional status.
• Individual lifestyle factors – poor hand-washing practices, poor sanitation coverage,
unsafe water consumption, unhygienic food preparation, storage and consumption
in view of the scarcity of water and basic food supplies in the country.
• Social and community networks – consumption of contaminated food at funeral
gatherings; traditional practices of preparing the dead for burial; practice of
handshaking at funerals; history of frequent travelling including to cholera-affected
areas; belonging to a religious sect which discourages seeking medical attention.
• Living and working conditions – declining access to safe water and improved
sanitation; poor personal hygiene.
• Poor perception of health delivery system by communities – communities lost
trust in the established health care delivery system that was no longer offering
comprehensive services.
As such, while the outbreak became known initially to the MOHCW as a health emergency,
it was clear that controlling the outbreak and preventing the ongoing spread required a
multisectoral response with the cooperation and collaboration of multiple stakeholders
at all levels.
3. Methodology
This study follows a comprehensive desk review of documented response efforts to the
cholera outbreak of 2008/09. Key informants were identified and interviewed to provide
their experiences of the outbreak and suggest what could have been done differently. The
study also assessed whether the multisectoral collaboration contributed to addressing
From a crisis response to institutional capacity building:
the social and other determinants that caused and propagated the outbreak.
Experiences from Zimbabwe on cholera outbreak
4. Results
Following the declaration of a national emergency by the Minister of Health and Child
Welfare on 9th December 2008, a Cabinet-level multisectoral Task Force was immediately
established to coordinate the government response to the situation. Chaired by the
Ministry of Local Government and Urban Development with the Civil Protection Unit as
secretariat, the Task Force brought together high-level leadership (including Ministers
and Permanent Secretaries) to provide policy direction on the response to the outbreak.
Representation included:
4• Office of the President and Cabinet
• Ministry of Health and Child Welfare
• Ministry of Water Resources and Infrastructural Development
• Ministry of Finance (Reserve Bank of Zimbabwe)
• Ministry of Energy and Power Development
• Ministry of Information and Publicity
• Ministry of Home Affairs
• Ministry of Transport and Communications
• Ministry of Defence
• Ministry of Foreign Affairs
This was supported by a working group of senior officials and a command centre
with various subcommittees to take forward the work. Unfortunately, the Task Force’s
effectiveness was limited by lack of resources to meet all of the identified needs. In addition,
the meetings were infrequent and often lacked a quorum, making binding decisions
difficult or impossible. Several countries including Namibia, South Africa, Zambia, China
and Russia responded with donations in cash and kind, including IV fluids, bicycles and
other commodities. But given the prevailing context in the country, some donors and
governments were reluctant to provide funds directly to the Government of Zimbabwe.
For this reason, and after being officially approached by the Government of Zimbabwe,
WHO simultaneously strengthened the United Nations Humanitarian “Cluster” system
of responding to emergencies, with a Health Cluster chaired by WHO, a WASH (Water,
Sanitation and Hygiene) Cluster chaired by UNICEF, and formation of a new Logistics
Cluster chaired by the World Food Programme (WFP). The new entity, the “C4” (Cholera
Command and Control Centre), co-chaired by the MOHCW and WHO, was established
to facilitate the scaling up of interventions to fight cholera and coordinate the work of a
very wide range of agencies and NGOs providing critical support for implementation
of the response in the form of finance, equipment, manpower, medicines and medical
sundries. The C4 also coordinated the inputs of key technical expertise, including from
the International Centre for Diarrhoeal Diseases Research in Bangladesh, the US Centers
for Disease Control and the Global Outbreak Alert and Response Network. Resources
were mobilized for the work of C4 and its partners from a variety of donors, including
the African Development Bank, AusAid, Government of Botswana, Central Emergency
Response Fund, United Kingdom Department for International Development, ECHO,
From a crisis response to institutional capacity building:
Government of Greece, Republic of Korea, SIDA, OFDA/USAID, World Vision Australia,
Canada and the USA.
Experiences from Zimbabwe on cholera outbreak
The MOHCW acted as the focal point between both the C4 and the multisectoral
government Task Force to ensure coordination of all actions across a wide range of
government and nongovernmental agencies as shown in Figure 3.
Figure 3: Relational context of the multisectoral coordination mechanisms
5A number of different processes were required to take place simultaneously to address
the challenges and these are described under the five thematic areas of the C4 response
model, having been chosen by the MOHCW and WHO as the main strategic framework
within which to fight the outbreak.
The core interventions decided upon were based around five main pillars identified within
the C4, with the key objectives / tasks outlined within each pillar as shown in Figure 4
below:
Figure 4: Cholera Command and Control Centre’s organizational structure
Source: Establishment of Cholera Command and Control Centre (C4) in Zimbabwe, Ministry of Health and Child Welfare, Zimbabwe,
and the World Health Organization; December 2008.
While the C4 originally operated at the national level, it was also planned to have
decentralized structures at provincial level to assist in lower-level coordination. However,
the roll-out of the decentralized structures was delayed until March 2009. In the interim,
provincial and district levels established or maintained their existing structures and plans
for mobilizing resources and coordinating the response to an outbreak through revitalizing
From a crisis response to institutional capacity building:
their disease control committees, civil protection committees or formation of new Cholera
Action Committees (CACs) composed of all organizations operating at that level, which
Experiences from Zimbabwe on cholera outbreak
then developed local plans to manage the outbreak.
Surveillance/laboratory: Data on the cholera outbreak was initially not readily available
although this changed following the declaration of cholera as a national emergency. Some
partners had readily available resources (transport, fuel, phones) to collect and transmit
data, and so had more up-to-date data than the MOHCW. The C4 helped to capture
this information and use it to guide action. Key people involved in the surveillance data
were the nursing staff, district medical officers, provincial and district health information
officers, provincial medical directors, environmental health officers, environmental
health technicians on motorbikes and the health information and surveillance unit of the
Epidemiology and Disease Control Directorate. Official communication on the cholera
outbreak was through the Minister of Health and designated offices of the PMDs and city
6health departments in order to reduce confusion and panic through uncoordinated cholera
statistics. Data from cholera treatment centres (CTC), districts and provinces was used
to develop the weekly epidemiological bulletins that were posted on the WHO website.
Stool samples were collected from selected patients to be sent for laboratory confirmation
of cholera; however, challenges with regards to availability of transport means, physical
transportation of specimens and generally reduced lab capacity presented an ongoing
challenge and therefore limited the number of confirmed cholera cases in this outbreak.
Case management: Case management was initially un-standardized and, in some
instances, based on old and outdated guidelines. Following this realization, appropriate
case definitions and management protocols for the different clinical scenarios were
developed and disseminated to the health facility and cholera treatment centres and units.
At the height of this outbreak, up to 400 CTCs/CTUs had been established at hospitals,
clinics and independent sites to increase access to care and so reduce deaths. These
were set up by the MOHCW and, with the support of partners, had infection control as a
key protocol to be followed.
Initially, essential items such as oral rehydration solution (ORS), IV fluids and antibiotics
were not available or were inadequate in quantity due to the scale of the outbreak. This
later improved with the support of partners and these improvements translated into a
corresponding decrease in the CFR as the outbreak evolved. The prevailing shortage of
manpower was addressed partially when some of the health workers returned to work to
assist with the crisis but the shortage of skilled manpower persisted. The newly-qualified
Primary Care Nurses were not competent to manage the case-load due to inadequate
experience and training. While the government failed to pay allowances for the few health
care workers manning the busy CTCs/CTUs, some donors and partners provided varying
amounts for daily or weekly duties, and this caused discrepancies in the staffing rates at
these centres.
WASH: The water and sanitation situation in the country was a key determinant causing
and driving the outbreak. As such, the activities of the water sector were crucial in
controlling the outbreak and preventing future outbreaks. The WASH Cluster enjoyed
participation by over 100 partners who were engaged in assisting with water, sanitation
and hygiene improvements at all levels, especially at grass-roots level. The members
contributed to the improvement of safe water supplies in schools and health facilities,
From a crisis response to institutional capacity building:
assessing CTCs, training of EHTs in infection control within CTCs, provision of non-food
items (buckets, soap, aquatabs), assessing the availability of materials for water quality
Experiences from Zimbabwe on cholera outbreak
testing, providing emergency water supplies, and establishing a rapid response team in
each province. A joint health-WASH social mobilization working group was formed with
the goal of building capacity of individuals, families and communities to prevent cholera,
launching a clean-up campaign in September 2009 in conjunction with the Ministry of
Environment, with support from the Deputy Prime Minister under the theme “Celebrating
a cholera-free Zimbabwe, celebrating a litter-free Zimbabwe”. Participatory hygiene and
health education programmes were revitalized as a key intervention in preventing further
outbreaks by targeting behavioural change at the community level. Support was also
provided to improve urban water safety in Harare and other major cities as from February
2009, when UNICEF began donating water treatment chemicals to local authorities to
enable safe water to be provided to residents. This support continued until mid-2012.
7Addressing the water situation in the country requires a medium- to long-term
development programme to address the pumping capacity, reticulation system, and the
logistics of adequate water treatment chemicals. A number of studies and proposals
for addressing these water supply challenges, particularly for urban areas, have been
developed. However, the implementation of these plans requires resources for long-
term financing. The same determinants of the cholera outbreak however, persist, with the
country continuing to struggle in raising finance for large capital projects and some major
donors unable to provide direct budgetary support to government for such projects.
Social mobilization: Social mobilization interventions were conducted during and after
the outbreak, aimed at sensitizing communities on cholera, the actions to be taken and
the preventive measures to be put in place. A running message on radio and TV was put in
place prior to the declaration of the emergency, and following the declaration, the intensity
of social mobilization increased and only scaled down as the outbreak came under control.
A social mobilization committee was formed to provide technical guidance to the national
cholera campaign. This committee included officers from the MOHCW Health Promotion
Department, WHO, WASH cluster representatives, and the National Healthcare Trust of
Zimbabwe to develop and review the IEC materials, including radio messages, cell phone
messages, TV and print media. Massive health education campaigns were conducted
by sending teams into villages and schools. The MOHCW also wrote to the education
sector to make sure that primary and secondary schools were responsive to the water
and sanitation measures and knew when to make contact with health workers promptly
if needed. The Ministries of Youth, Local Government and Education were trained at all
levels on cholera issues, and campaigns targeting the community were continuously
given critical importance of sustained control. Communication was also conveyed to all
involved that schools were not to be used as cholera treatment centres.
Logistics: Logistical support was crucial to the success of controlling the outbreak. Basic
supplies including buckets and soap were inadequate in the country. It was noted by
partners that a major challenge was inequitable distribution of resources, with supplies
being delivered to one specific CTC rather than to the district hospital for onward equitable
distribution to all CTCs in the vicinity. This partly resulted from the limited governance
and oversight by the MOHCW, transport and fuel shortages which resulted in resources
being delivered to the most accessible areas, with distribution of supplies not always
in line with the severity of the outbreak in affected areas. Supplies were also frequently
From a crisis response to institutional capacity building:
delayed in arriving from where they were being procured as a result of suppliers being
overwhelmed and having insufficient stocks. This was further complicated by the raised
Experiences from Zimbabwe on cholera outbreak
costs of supplies due to import duty on supplies not organized through the MOHCW
before the declaration of the outbreak as an emergency. However, the subsequent arrival
of more donors greatly improved the situation in terms of supplies. Logistics clusters were
put in place at decentralized levels with district-level stakeholders meeting frequently in
order to share responsibilities and avoid duplication of effort in managing the logistics.
Resource allocation: Resources were mobilized from many sources, including from the
Government of Zimbabwe/Reserve Bank of Zimbabwe, development partners, donors,
bilateral agencies and NGOs. Donations were received both in “cash” and “in kind”
in the form of commodities. All resources were managed in the first instance through
NATPHARM, the national pharmaceutical storage and distribution facility. Logistical and
financial support was provided to NATPHARM from C4, WFP, UNICEF and other partners
8such as Medicines san frontiers (MSF). Logisticians and epidemiologists worked together
to create a “formula” to quantify supplies needed by each CTC based on number of
cases and other epidemiological data.
5. Cost
Estimating the total cost of the cholera outbreak of 2008/9 and the response is complex
but important given the persisting determinants and likelihood of recurrence. However,
this will require expertise considering the large number of governments, donors and
stakeholders involved, the mixture of contributions in cash and in kind, as well as the
prolonged time period of over three years. Contributions to the Health Cluster were
estimated at US$ 36.2 million in 20093, but this does not include non-health cluster
actions including contribution of Zimbabwe and other governments. The total cost of the
response is, therefore, expected to be much higher.
Monitoring of cholera cases continues through the routine MOHCW surveillance system,
which has managed to detect other smaller outbreaks following the massive 2008/9
outbreak. Training of health workers and communities in the WHO-recommended
integrated disease surveillance and response (IDSR) is being continued. Data from
this system is used to inform areas where priority action is needed to rapidly contain
any outbreaks, with deployment of rapid response teams that have been trained by the
MOHCW with support from WHO following the cholera outbreak.
IMPACT 1: Reduction in cholera cases
The health sector-specific and combined multisectoral efforts described here ultimately
resulted in the control of the worst-ever cholera outbreak to hit Zimbabwe. This outbreak
raged from end- August 2008 and was declared officially over on 26 July 2009. There
have since been continued reports of sporadic outbreaks and the multisectoral measures
put in place since December 2009 have enabled the country to bring about dramatic
reductions in both cholera cases and deaths across the country. There have been no
cholera cases reported from week 23 of 2011 to week 20 of 2012.
Figure 5. Cholera epidemic curve, Zimbabwe, from Week 5, 2010 to Week 26, 2011
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
Source: Ministry of Health and Child Welfare, Zimbabwe, Weekly Disease Surveillance System; August 2011
3
Health Cluster Bulletin No.15 2009 MOHCW, WHO
9Improved awareness by people about cholera, improved behaviour towards personal
hygiene including hand washing and improved environment in terms of safe water and
sanitation resulted in improved quality and quantity of water being provided to some
areas of the population. However, the CFR remained high and this may be due to delays
in patients with cholera seeking care, particularly among certain religious groups, and
unpredictability of outbreak spots.
IMPACT 2: Improved state of readiness
The country has learned and evolved a great deal as a result of the severe cholera
outbreak. It was clear that the health system was overwhelmed by the sheer scale of the
outbreak at the onset, and many lessons have been learned and systems established
at national and sub-national levels to enable future response to disease outbreaks. This
includes development of updated Integrated Disease Surveillance and Response (IDSR)
guidelines; updated training modules for health workers; case management training for
epidemic diarrhoeal diseases; Zimbabwe cholera control guidelines including guidelines
on food hygiene; and training of Rapid Response Teams at district level4.
IMPACT 3: Harmonized action by multiple stakeholders
There is now much greater harmonization of action across both government and
nongovernmental agencies, with all stakeholders using the same sets of guidelines under
the leadership of the Department of Epidemiology and Disease Control in the MOHCW.
Continued coordination is facilitated through the ongoing cluster system, although its
transition towards a more development-oriented model is an ongoing discussion.
IMPACT 4: Strengthening of the health system
The health system was strengthened as a result of the actions of the MOHCW, the Health
Cluster and other stakeholders, with improved medical and equipment supply to health
institutions and an increase in community confidence in the health care system as the
response to the outbreak progressed.
Data on changes in health inequities are hard to identify within available documentation.
Routine data on cholera cases and deaths are disaggregated by age and place of
residence but not by sex, wealth quintile, educational level, occupational level or other
markers of potential inequity. This in itself reveals the future importance of gathering data
that specifically explores potential inequities through deeper exploration of the distribution
From a crisis response to institutional capacity building:
of disease. Key social determinants of health in Zimbabwe’s cholera epidemic relate to
hygiene practices, access to safe water and sanitation, poverty and the functionality of
Experiences from Zimbabwe on cholera outbreak
the health system itself. The general socioeconomic situation remains fragile, and while
there have been improvements in the health system as a result of concerted efforts by
the MOHCW and partners, the system remains weak in all pillars (human resources,
health information, health financing, health service delivery, commodities and products).
Funding for health from the central government and private sector donors remains low
while disposable incomes remain poor.
4
Meeting on Preparedness, Detection, Alert and Response Strategy for Outbreaks, 28 - 29 April 2009, Elephant Hills Hotel, Victoria
Falls, Zimbabwe.
10Follow-up and lessons learnt
A number of key facilitators and barriers were observed in the response:
Facilitating factors in the response Barriers in the response
• Convergence of purpose: all stakeholders • The health system was at its weakest, and weak
united in their determination to avoid further in every pillar, at the onset and throughout the
loss of life outbreak
• Changing of the political climate in February • Potential confusion with the large number of
2009 with the formation of the Government of partners who had to be well-coordinated
National Unity • Political situation at the onset of the outbreak
• Change of currency: with dollarization to the affected communication, collaboration and
US dollar, logistical issues were made easier funding
• Low community capacity, knowledge and
awareness
The outbreak was declared over on 26 July 2009 but stakeholders remained on high
alert given the continued existence of predisposing factors in the social determinants of
health. All relevant sectors continued working to prevent further outbreaks, in particular
addressing the water and sanitation issues in which there has been an improvement
over time, with increased supplies of clean water being provided across the country,
particularly in urban areas. The structures put in place to manage the severe cholera
outbreak remain to this day in an effort to continue controlling cholera which remains
a threat. However, there have been important developments and transitioning of the
objectives and the way work is done. For example:
The Ministry of Health and Child Welfare - The MOHCW stepped up training in Emergency
Preparedness & Response (EPR), Integrated Disease Surveillance & Response (IDSR)
and Rapid Response Teams (RRT) and ongoing social mobilization campaigns. The
health system has seen progressive strengthening following the launch of the National
Health Strategy 2009-2013, and resource mobilization through the development and
launch of the Health Sector Investment Case.
The National Task Force on Epidemic-Prone Diseases – This group continued to meet
monthly and now once quarterly and has a particular focus on addressing the issues
of epidemic-prone diseases. Work is at an advanced stage of transforming this task
force into a standing committee for both planning and response, while work is also at an
advanced stage on the formulation of a policy, strategy and legislation for an enhanced
From a crisis response to institutional capacity building:
Cabinet Committee for Disaster Risk Management. This will legislate for the standard
response model used to control cholera, but will include an expanded platform in the
Experiences from Zimbabwe on cholera outbreak
command centre to enable inclusion of all stakeholders in the response (government
departments, UN agencies, NGOs, private sector, churches, universities, etc.). This
group has also been working hard with local authorities and ZINWA (Zimbabwe National
Water Authority) and relevant ministries to improve the water and sanitation situation
countrywide, although there is still a long way to go.
The C4 – The C4 continues to operate but now functions mainly in support of surveillance
of cases and support to the MOHCW for rapid follow-up of any outbreaks, with staffing
being scaled down to three people. At the same time, plans are in progress to transfer
all functions of C4 to the MOHCW within a purpose-built Emergency Operations Centre
(EOC) with funding from ECHO, with C4 functions continuing during the transition phase
to ensure no gap in surveillance or capacity to respond quickly to outbreaks as needed.
11It should also be noted that the unprecedented scope of the outbreak required innovative
response mechanisms to be developed, and many of the tools and processes have
already been shared at the international level (e.g. Zimbabwe’s Cholera Command and
Control Centre model was provided to Cameroon in 2010 to support them in their cholera
outbreak; the C4 model has been disseminated and adapted in a number of locations,
including Haiti).
While for now the cholera situation in the country is under control, future sustainability
is dependent on successful national transition from an emergency funding mode to a
comprehensive development platform that ensures all social determinants of health
driving disease outbreaks are addressed in a sustainable manner in the longer term.
Key lessons on social determinants of health and cholera for Zimbabwe
• The Ministry of Health and Child Welfare must take the lead in coordinating a
multisectoral response to disease outbreaks with social causes, and it needs
to be mandated/supported to do so by the highest level of the government in its
stewardship role.
• Responding to an outbreak requires addressing the health emergency at the same
time as the determinants of health – stakeholders outside the health sector need to be
identified, made aware of their responsibilities and given a central role in responding.
• Without a strong, well-responding health system including human resources for
health, material supplies and raising community awareness, it is not possible to
contain an epidemic.
• The emergency became an opportunity to work towards better preparedness
in responding to future outbreaks using a multisectoral approach and better
coordination.
• Data on health inequities and the social determinants of health need to be
systematically gathered and documented as part of the ongoing work of the MOHCW.
6. References
From a crisis response to institutional capacity building:
Experiences from Zimbabwe on cholera outbreak
1. Evaluation of the Health Cluster Response to the Cholera Outbreak in Zimbabwe,
Centre for the Evaluation of Public Health Interventions (CEPHI), College of Health
Sciences, Department of Community Medicine, University of Zimbabwe, and the
World Health Organization.
2. Meeting on Preparedness, Detection, Alert and Response Strategy for Outbreaks,
28 - 29 April 2009, Elephant Hills Hotel, Victoria Falls, Zimbabwe.
3. Health Cluster Bulletin No.15, 2009, Ministry of Health & Child Welfare and WHO.
12ISBN 978-929023261-2
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